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Comparative Study of Uterine Adnexal Mass by Transabdominal and Transvaginal Ultrasonography

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Comparative Study of Uterine Adnexal Mass by Transabdominal and Transvaginal Ultrasonography IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 15, Issue 4 Ver. II (Apr. 2016), PP 50-64 www.iosrjournals.org Comparative Study of Uterine Adnexal Mass by Transabdominal And Transvaginal Ultrasonography Dr. Kedarnath Pal M.D. I. Introduction In our country poor living condition, social taboo and child marriage have resulted in increased incidence of diseases related to genitourinary system. Of these, adnexal mass forms a large proportion.The first major application of ultrasound was done in 1912 to search for Titanic. First ultrasonic generator was made in France in 1917. In 1950 first clinical use was done by Howry et al when he scanned the abdomen with subject immersed in water. In 1950 Ludwig & struthers used it to detect foreign body & gallstone. In 1956 Mudt & Hughes used Ophthalmic by A Scan. Together with Mac Vicar & Brown, Ian Donald of Glasgow developed the first 2-D contrast scanner in 1958. Kossof of Australia described the modern high resolution gray scale technique in 1972. The first stage of Transvaginal Sonography (TVS) was the A-mode technique. First it was used by kratochwl (in 1969). The major breakthrough in TVS came in 1984-85 with the development of modern vaginal sector scanner. Since the advent of ultrasound, it has been applied to the imaging of pelvic organs, but the success was moderate. So, whereas ultrasound improved obstetrical management dramatically it merely added to the diagnostic armamentarium for the gynaecological patients. Early diagnosis of adnexal mass is essential to reduce morbidity. However, with the advent of modern scanner with high resolution & TVS, things have taken a better turn. Beginning with humble origin, TVS has now become an indispensible tool for gynaecological imaging. The fine details provided by TVS about the anatomy and pathology of pelvic viscera is unparalled by any other imaging modality. Conventionally, Transabdominal ultrasonography (TAS) of female pelvis is performed. But, inadequate depth of penetration of ultrasound waves resulting in poor image quality of deep pelvis structures, need for full ladder & obesity limit its use. TVS overcomes some of the limitations of conventional TAS. The central placement of the pelvic structures especially in obese patients is a problem. Since the tranvaginal probe is placed in close proximity to the pelvic structures higher frequency ultrasound can be utilized which can improve morphologic details of pelvic structures with better resolntion (Frederick et al 1991). However there are certain distinct advantages of TAS – larger field of vision, ability to image deeper structures better, simultaneous evaluation of other abdominal organs. TVS can not be used in virgins, children & elderly woman with narrow introitus. Thus it can be safely concluded that TAS & TVS are not competiting, but supplementary to each other Other methods of imaging the adnexal region are Doppler, CT scan & MRI. Doppler sonography can determine pualitative and quantitative features of blood flow in the pelvic vessels. CT of the pelvis is unsuitable as a routine diagnostic measure for primary assessment of gynaecologic problems. It can be used for preoperative staging, diagnosis of local recurrence, monitoring, follow up in all gynaecological neoplasms & planning radio therapy in malignant neoplanms (Hall 1994). MRI is becoming the primary modality for evaluating gynaecological malignancy (Hricak 1983). The multiplanar imaging capability, excellent soft tissue contrast & large field of vision offer distinct advantages over USG & CT in the assessment of adnexal pathology. II. Aims & Objectives I) Evaluation of adnexal mass by transabdominal & tranavabjnal sonography. II) Detection of specific sonomorphologic features which are better detected by TVS than TAS. III) Determination of the usefulness of USG in the detection & specific diagnosis of adnexal masses in the study group. IV) Identification of cases in which TVS yielded more, epual or less information than TAS & hence detection of cases in Which TVS provided diagnostic, contributory or worse information. V) Evaluation of specificity & sensitivity of TAS & TVS. III. Materials & Methods The present study was undertaken in the Radiology Department of R.G.Kar Medical College in collaboration with the Gynaecology & Obstetrics department . DOI: 10.9790/0853-1504025064 www.iosrjournals.org 50 | Page Comparative Study Of Uterine Adnexal Mass By Tran abdominal And Transvaginal Ultrasonography Materials: a) Patients – The patients referred from G&O dept & diagnosed sonologically to be suffereing from adnexal mass were included in this study. b) Machine – The machine used in this study included secter probe of 3.5 MHZ, 5MHZ. A multifocal automatic camera was used for taking picture. Transvaginal Scans were performed using 7.5 MHZ TVS probe. Methods: The patients who were clinically snspected of having an adnexal mass constituted the study group. All these patients were referred from G&O dept- both Indoor & Outdoor section. They were examined in the following way: i) History & Clinical examination ii) Transabdominal sonography iii) Transvaginal sonography iv) The patients were followed up, their FNAC and/or operative findings were collected and compared with the previous findings and diagnosis. v) Rescan, whenever passible to reassess the sonological findings with final diagnosis. TAS was performed on all the patients. In addition, TVS was done in a subset of patients in whom the mass was predominantly pelvic in location. All TAS scans were performed using full bladeer as an acoustic window for opimum visualisation of pelvic ciscera. Adequate amount of coupling gel was applied to the skin surface. Scanning was done in longitudinal, transverse and oblique axes. After completion of TAS, the procedure of TVS was briefly explained to the patient and verbal consent was obtained. Prior to the examination patient was asked to empty her bladder. Scanning was performed in the lithotomy position with the patient supine, her thighs abducted and knees flexed. The probe was covered with a condom containing small amount of gel. Additional gel was placed on the outside of the sheathed tip. In patients with complaint of infertility, water or saline was used instead of gel as the latter has spermicidal action (Timor- Trish 1994). Once the transducer was positioned in the vagina it was manipulated to obtain the appropriate image of uterus, ovaries, parametrium and pelvic side walls. Three basic maneuvers are possible which are : 1. Advancement or withdrawal of the transducer along the axis of the vagina. 2. Angling the transducer tip from side to side or anterior to posterior. 3. Rotating the transducer along its long axis. When the transducer was inserted, the cervix and lower uterine segment were visualized initially. The probe was advanced cephaled until the uterine fundus came into view. The transducer was then oriented to obtain a long axis view of the uterus containing the endometrium. Side to side movement of the probe was done to visualise other areas of the uterus. Then the probe was angulated laterally to bring into focus. The ovaries and adnexae are evaluated in both long axis and short axis views. In case of anteriorly or highly placed ovaries, compression was applied to the lower abdomen in order to bring them within the range of ultrasound beam. To image the cul-de-sac, a steep posteror angulation of the probe was necessary. The lower uterine segment, the retroverted uterine fundus and the remaining pelvic could be evaluated only in near coronal and near sagittal planes due to the orientation of these viscera to the vaginal fornix. True transverse image could only be obtained in the anteverted uterine fundus (Lamde et al 1988). When real time scanning was performed, simultaneous pressure was applied to the pelvic organ under study both with the ultrasound probe and transabdominally with the sonographer’s free hand in order to assess the presence of pelvic adhesions. En bloc motion of contiguous viscera, rather than independent motion of the uterus, ovaries and oviducts or fixation of bowel loops were considered a sign indicative of pelvic adhesions (Lande et al 1988). After detection of a mass by sonography, first of all, attempt was made to determine whether it is ovarian or extraovarian in location. Size of the mass was noted (Maximum of the 3 dimensions was considered for reporting the Size). If the size was less than 10cm, TVS was performed in addition. The ovarian masses thus detected were initially grouped as cystic, complex of solid depending on their sonographic appearance. Following criteria were used (Luxman 1991). Cystic: Anechoic or with diffuse low level internal echoes without mural nodules, solid parts or septations. Complex: Mixed echogenecity with presence of mural nodules or septations or irregular solid parts. Solid: Predominantly solid in echogenecity. In case of a cystic or complex mass, presence or absence of internal echoes, thin septations (<3mm), thick septations (> 3mm), mural modules, daughter cysts, irregular solid areas were noted. In a predominantly solid lesion, it was noted whether it showed homogeneous or heterogeneous echopattern. The sonographic criteria for diagnosing different ovarian masses were adopted from Fried (1985) and Rottem et al (1990). Malignant pattern was suggested in the presence of thick septae, irregular solid parts, mural nodulations ascites DOI: 10.9790/0853-1504025064 www.iosrjournals.org 51 | Page Comparative
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